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HomeMy WebLinkAboutMiscellaneous - 66 SUNSET ROCK ROAD 4/30/2018 (2) 66 SUNSET[ROCK ROAD- ad 210/106.A-0267-0000.0 I { i I � i I i i I I I i i Commonwealth of Massachusetts City/Town of System Pumping Record NORTH ANDOVER Form 4 h DEP has provided this form for use by local Boards of Health. Other forms may be used,but the information must be substantially the same as that provided here. Before using this form,check with your local Board of Health to determine the form they use.The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 CMR 15.351. A. Facility Information Important: When filling out 1. System Location: Corms the computer.use only the tab key Address M -nfl/m1 to move your � OvG cursor-do not ---— - ---... CityfTovrn Stale Zip Code use the return r key. 2 System Owner: c -JAN �U15 Name Address(if different from location) LH Cityfrown State Zip Code Telephone Number B. Pumping Record 1. Date of PumpingDate — - — — 2. Quantity Pumped: Gallons - 3. Type of system: ❑ Cesspool(s) 01s-eptic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe) 4. Effluent Tee Filter present? ❑ Yes 2!1'*'No if yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. System Pumped By: Name �� / Vehicle License Number -._... -- - -- — - - ...­­.. Company 7. Location where contents were disposed: G.L.��.�. North Signature of Flamer Date -- — Signature of Receiving Facility Date I5form4.doc•03/06 System Pumping Record•Page r of t •;,: MAP # -13LOT # PARCEL # STREET _ .___.�_...._ c _ . CONSTRUCTION_APPROVAL HAS PLAN REVIEW FEE BEEN PAID? ES NO PLAN APPROVAL: DATE _ PP. BY__� _ . DESIGNER: ///�!/ PLAN DA I*E._��1 CONDITIONS WATER SUPPLY: N WELL WELL PERMIT ���� DRILLER._...___.__...__.__._.._._.__.._........ .............. .._..... _. . WELL TESTS: CHEMICAL DALE APPROVED._..._.___•__..__._.___. C,TERIA I DA I E (IPPRUVED BACT IA II DALE COMMENTS: FORM U APPROVAL: APPROVAL TO ISSUEYES NO DATE ISSUED / ( '7� BY CONDITIONS: FINAL APPROVAL: ALL PERMITS PAID NO WELL CONSTRUCTION APPROVAL NO SEPTIC SYSTEM CONSTRUCTION APPROVAL !ES�� NO OTHER YES NO ANY VARIANCE NEEDED YES NO � FINAL BOARD OF HEALTH APPROVAL: DATE:.b_......__ ll�?.,©Y: ..,�/j l RECEIVED Commonwealth of Massachusetts AUG 0 2.0'7 City/Town of TOWN OF NOPTH cR HEALTH D rrcA�00T System Pumping Record NORTH ANDOVER Form 4 DEP has provided this form for use by local Boards of Health. Other forms may be used, but the form, check with our ialt the same as that provided here. Before using this Y information must be substantially tufo Y local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days from the pumping date in i accordance with 310 CMR 15.351. A. Facility information ; Important: When tilling out 1. System Location: forms on the computer.use .�Q_ �lonly the tab key Addle /�_- p C to move your V 1/ nd cursor-do not —. __..._...... ..... City/Town Stale Zip Code use the return key. 2 System Owner: ve Name .a Address(if different from location) " City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping - 7J/= 2. Quantity Pumped: Ga �- 00 Date 3. Type of system: ❑ Cesspool(s) otic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? es ❑ No if yes, was it cleaned? Yes ❑ No 5. Condition of System: , G.L: I): �)rth Anddvdt, MA. 6. System Pumped By: Wind RWer Environmental Name r63 VYestcrn Ai+e. VehlcleKicense Number Company 7. Location where contents were disposed: � Z— S Signat e of Hauler Date — Signature of Receiving Facility Date 15farm4.doc•03106 System Pumping Record•Page t of t �E_PTiG-MalkLJ __9j8U ''UEX •ti t _ S E •INSTALLER +LICENSED :.. NO •I '•• :. �is a TYPE. OF CON5TRUCTION: ? NEW REPAIR' NEW CONSTRUCTION: CERTIFIED PLOT. PLAN REVIEW• NO CONDITIONS OF..APPROVAL Y NO (FROM FORM U)t 4t r ;•. _•`,ISSUANCE OF DWC PERMITgYE NO DWC PERMIT N0. +INSTALLERSGov BEGIN INSPECTION '..J. - EXCAVATION .•INSPECTION: : NEEDED: PASSED CONSTRUCTION INSPECTION: NEEDED: AS BUILT PLAN SATISFACTORY: YES APPROVAL. TO BACKFILL: DATE: ZIA— ' � ���' FINAL . GRADING APPROVAL: DATE BY �7. : FINAL CONSTRUCTION APPROVAL: DATE: BY ~ 577 MAIN STREET HUDSON,MA 01749 �lECF s 800-499-1682 'AUG TOWN ! WIXD I?I V-ER ENVIRONMENTAL SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PROPERTY OWNERS NAME: SERRAO GREGORY PROPERTY ADDRESS: 66 SUNSET ROCK RD, NO. ANDOVER, MA 01845 ADDRESS OF OWNER: SAME (IF DIFFERENT) DATE OF INSPECTION: JULY 18,2005 NAME OF INSPECTOR:THOMAS CHIGAS COMMONWEALTH OF MASSACHUSETTS f EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS d DEPARTMENT OF ENVIRONMENTAL PROTECTION ve RRELE1 V F AUG 6 �,;5 TITLE 5 TOWN OF n:. OFFICIAL INSPECTION FORM—NOT FOR VOLUNTA H SMENTS� SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 66 SUNSET ROCK RD. NO.ANDOVER,MA 01845 Owner's Name: SERRAO,GREGORY Owner's Address: 66 SUNSET ROCK RD. NO.ANDOVER,MA 01845 Date of Inspection: JULY 18,2005 Name of Inspector: (please print)THOMAS CHIGAS Company Name: Windriver Environmental Mailing Address: 577 Main Street Hudson,MA 01749 Telephone Number: 800-499-1682 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as.of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: YES Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: JULY 18,2005 The system inspector shall submit a copy of is inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:66 SUNSET ROCK RD. P NO.ANDOVER,MA 01845 Owner: SERRAO.GREGORY Date of Inspection:JULY 18,2005 Inspection Summary: Check B,C,D or E/ALWAYS complete all of Section D A. System Passes: YES I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: NO One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please explain. NO The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: NO Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): NO broken pipe(s)are replaced NO obstruction is removed NO distribution box is leveled or replaced ND explain: NO The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): NO broken pipe(s)are replaced NO obstruction is removed ND explain: Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 66 SUNSET ROCK RD. NO.ANDOVER,MA 01845 Owner: SERRAO,GREGORY Date of Inspection:JULY 18,2005 C. Further Evaluation is Required by the Board of Health: NO Conditions exist which require further evaluation by the Board of Health in order to determine if the system is Tailing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: N/A Cesspool or privy is within 50 feet of surface water N/A Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: NO The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. NO The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. NO The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. NO The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**.Method used to determine distance **This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: N/A Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 66 SUNSET ROCK RD. NO.ANDOVER,MA 01845 Owner: SERRAO,GREGORY Date of Inspection:JULY 18,2005 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No NO Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool NO Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool NO Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool N/A Liquid depth in cesspool is less than 6"below invert or available volume is less than'/2 day flow NO Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped NO Any portion of the SAS,cesspool or privy is below high ground water elevation. N/A Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. N/A Any portion of a cesspool or privy is within a Zone 1 of a public well. N/A Any portion of a cesspool or privy is within 50 feet of a private water supply well. N/A Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] NO(Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes no N/A the system is within 400 feet of a surface drinking water supply N/A the system is within 200 feet of a tributary to a surface drinking water supply N/A the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone 11 of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. 4 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 66 SUNSET ROCK RD. NO.ANDOVER,MA 01845 Owner: SERRAO,GREGORY Date of Inspection:JULY 18,2005 Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No YES Pumping information was provided by the owner,occupant,or Board of Health NO Were any of the system components pumped out in the previous two weeks? YES Has the system received normal flows in the previous two-week period? NO Have large volumes of water been introduced to the system recently or as part of this inspection? YES Were as built plans of the system obtained and examined?(If they were not available note as N/A) YES Was the facility or dwelling inspected for signs of sewage back up? YES Was the site inspected for signs of break out? YES Were all system components,excluding the SAS,located on site? YES Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? YES Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes No YES Existing information.For example,a plan at the Board of Health. N/A Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[3 10 CMR 15.302(3)(b)] Page 6 of 11 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 66 SUNSET ROCK RD. NO.ANDOVER,MA 01845 Owner: SERRAO,GREGORY Date of Inspection:JULY 18,2005 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):440 Number of current residents:6 Does residence have a garbage grinder(yes or no)?NO. Is laundry on a separate sewage system(yes or no):NO [if yes separate inspection required] Laundry system inspected(yes or no):N/A Seasonal use:(yes or no):NO Water meter readings,if available(last 2 years usage(gpd)):ATTACHED Sump pump(yes or no):NO Last date of occupancy:CURRENT COMMERCIALANDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203):_gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: OWNER Was system pumped as part of the inspection(yes or no)?YES If yes,volume pumped: 1.500aallons--How was quantity pumped determined?SIZE OF TANK Reason for pumping:CHECK TANK'S INTEGRITY TYPE OF SYSTEM YES Septic tank,distribution box,soil absorption system NO Single cesspool NO Overflow cesspool NO Privy NO Shared system(yes or no)(if yes,attach previous inspection records,if any) NO Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) NO Tight tank Attach a copy of the DEP approval N/A Other(describe): Approximate age of all components,date installed(if known)and source of information:9 YEARS,INSTALLED 1996 OWNER AND ASBUILTS Were sewage odors detected when arriving at the site(yes or no):NO Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 66 SUNSET ROCK RD. NO.ANDOVER,MA 01845 Owner: SERRAO,GREGORY Date of Inspection:JULY 18,2005 BUILDING SEWER(locate on site plan) Depth below grade: 57" Materials of construction: cast iron 4"40 PVC other(explain): Distance from private water supply well or suction line:N/A Comments(on condition of joints,venting,evidence of leakage,etc.):THERE WERE NO SIGNS OF LEAKAGE IN OR AROUND PIPE.SOILS WERE CLEAN AND DRY. SEPTIC TANK: YES(locate on site plan) Depth below grade:4' Material of construction:YESconcrete metal fiberglass_polyethylene other (explain) If tank is metal list age:_is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: 101L X 5'W X 5'H OUTLET INVERT A 4'2"=1,500 GAL Sludge depth: 10" Distance from top of sludge to bottom of outlet tee or baffle:28" Scum thickness:r2" Distance from top of scum to top of outlet tee or baffle:5" Distance from bottom of scum to bottom of outlet tee or baffle: 14" How were dimensions determined?ROD AND RULER Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.):THE TANK WAS PUMPED AND THERE WERE NO SIGNS OF LEAKAGE IN OR AROUND AREA,SOILS WERE CLEAN AND DRY.THE INLET AND OUTLET TEE BAFFLES ARE PVC AND IN GOOD CONDITION.THE MIDDLE COVER IS RAISED 6" UNDER GRADE. GREASE TRAP: NO(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 66 SUNSET ROCK RD. NO.ANDOVER,MA 01845 I Owner: SERRAO,GREGORY Date of Inspection:JULY 18,2005 TIGHT or HOLDING TANK:NO(tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity:_gallons Design Flow:_gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition_of alarm and float switches,etc.): DISTRIBUTION BOX: YES(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert:0" DEPTH BELOW GRADE: 66" Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.):THE BOX IS LEVEL AND EQUALLY DISTRIBUTING.THERE WERE NO SIGNS OF LEAKAGE OR FAILURE IN OR AROUND AREA SOILS WERE CLEAN AND DRY THERE IS ONE INLET AND FOUR OUTLETS ALL SCH40 PVC. PUMP CHAMBER: NO(locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): , • Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 66 SUNSET ROCK RD. NO.ANDOVER,MA 01845 Owner: SERRAO,GREGORY Date of Inspection:JULY 18,2005 SOIL ABSORPTION SYSTEM(SAS): YES(locate on site plan,excavation not required) If SAS not located explain why: Type Leaching pits,number: Leaching chambers,number: Leaching galleries,number: YES Leaching trenches,number,length:FOUR LINES YW X 54'L Leaching fields,number,dimensions: Overflow cesspool,number: Innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.):THERE WERE NO SIGNS OF FAILURE IN OR AROUND AREA.SOILS WERE CLEAN AND DRY.THE LINE ARE 4"SCH 40 PVC ALL IN GOOD CONDITION. CESSPOOLS:NO(cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY:NO(locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C. SYSTEM INFORMATION(continued) Property Address:66 SUNSET ROCK RD. ..NO.ANDOVER,MA 01845 Owner: SERRAO,GREGORY NOTE:SEPTIC SYSTEM CERTIFIED 9/11/95 Date of Inspection: JULY 18,2005 ELEVATIONS OUT OF HSE.=149.71 SKETCH OF SEWAGE DISPOSAL SYSTEM INTO TANK=149.25 Provide a sketch of the sewage disposal system including ties to�a e�permanent r, L"ks or benchmarks.Locate all wells within 100 feet.Locate where pub is water supply enters tV1J011djUl48.78 1 48.33 101.12 #3 =148.40 #4 =148.33 180.91 R=60.003 N L=100.00 tom 2 T. .W.=155.38 SUNSET ROCK #� 35' ROAD � r . c LOT #13 40,194 S.F. PLAN#12,544 N.E.R.D. D SQ LOT#14 I CERTIFY THAT OFFSETS SHOWN ARE FOR THE USE OF THE OFFSETS OF THE BUILDING INSPECTOR ONLY SHOWN COMPLY 1� AND SUCH USE IS FOR THE WITH THE ZONING DETERMINATION OF ZONING . 13972 BY LAWS OF fc/STI NORTH ANDOVER CONFORMITY OR NON-CONFORMITY %�tt LARDn,� WHEN BUILT WHEN CONSTRUCTED. Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 66 SUNSET ROCK RD. NO.ANDOVER,MA 01845 Owner:SERRAO,GREGORY Date of Inspection:JULY 18,2005 SITE EXAM Slope:YES Surface water:NONE Check cellar:YES Shallow wells:NONE Estimated depth to ground water 8'+(approx)feet Please indicate(check)all methods used to determine the high ground water elevation: YES Obtained from system design plans on record-If checked,date of design plan reviewed:9/11/95 YES Observed site(abutting property/observation hole within 150 feet of SAS) YES Checked with local Board of Health-explain: INFORMATION NO Checked with local excavators,installers-(attach documentation) YES Accessed USGS database-explain: MAPS You must describe how you established the high ground water elevation:THE HOME HAS 8'PRECAST FOUNDATION WITH NO SUMP PUMP AND THE BASEMENT WAS DRY.WHILE DIGGING IN YARD LOCATING SYSTEM,THERE WERE NO SIGNS OF(EHSGW)ADEPTHS OF 5'-6'.THERE WERE NO ABUTTING PROPERTS WELLS OR WETLANDS WITHIN 150'FROM SYSTEM. J a Summary Record Card generated on 7/12/2005 1:00:01 PM by Elaine Barclay Page 1 Town of North Andover Tax Map # 210-106.A-0267-0000.0 66 SUNSET ROCK ROAD SERRAO, GREGORY A. 66 SUNSET ROCK ROAD NORTH ANDOVER, MA 01845 Class 101 Single Family Property Type 1 Residential Size Total 0.92 Acres FY 2005 UB Mailing Index Name/Address Type Loan Number Active/Inact. From Until SERRAO, GREGORY A. Payor 66 SUNSET ROCK ROAD NORTH ANDOVER, MA 01845 UB Account Maint. Account No Cycle Occupant Name Active/Inactive Bldg Id. 3272.0- 66 SUNSET ROCK RD Last Billing Date 7/8/2005 3170347 03 Cycle 03 Active UB Services Maint. Service Code Rate Charge Multiplier/Users MISCFEE ADMIN FEE 1 1 9.18 1/ WTR WATER 01 ALL METER SIZE 135.74 /1 UB Meter Maintenance Serial No Status Location Brand Type Size YTD Cons 40219178 a Active ENC F.RT. NEPTUNE NEPTUNE w Water 1 1 0 Date Reading Code Consumption Posted Date Variance 6/13/2005 1198 a Actual 38 7/15/2005 20% 3/25/2005 1160 a Actual 40 4/5/2005 7% 12/14/2004 1120 a Actual 30 1/14/2005 -71% 9/24/2004 1090 a Actual 136 10/8/2004 190% 6/11/2004 954 m Manual estimate 25 7/30/2004 -4% 4/16/2004 929 a Actual 57 5/17/2004 0% Trouble Code:03 12/15/2003 872 n New Meter 0 12/15/2003 0% Ccmnticn _ Meter Info Werk trder ' Radyr 4 r Metes reacng:Serial number 0 462`1,811 ( 5 ......... Fig&C�@�... �&kkwI�Yi .fStf...li511,. .. ..i53..i� .4 �i5fi�..... ......... � i �[ '3 ...1. 6/13/2005 1198 38 20 a 7/15/2005 2 3/25/2005 1160 40 7 a 4/5/2005 i s:3 12/1412004 1120 30 -71 a 1/1412005 4 9/2412004 1090 136 190 a 1018120041 :€:5 6/11/2004 954 25 -4 m 7/3012004 I €E 4/16/2004 929 57 0 a 5/1712004 Trouble Code:03 ::€7 12/15/2003 872 0 0 n 12/1512003 gg P. d gof................................................................................................................................................................................................................................... ................................................................................................................................................................................................................................... �M 1.°y w• `�� ALL. :..'-•^,� .ate -� -ry.2 N7.„ .�.�...• SIZ, .'�. F `. a ei Editing Existing Record(111) j,"►, � rM77y Exit g]j Ea Cu YNW. .F �$ T t l x A... • A i � P i a m i _ iAco cc no �'"� • 01 e �t i i' 7'w ,5 z�£a 1 i i ►A -t i i. ♦i i. ►A i 11t -&' a-gx d t � " J , 6'3 got, . W ' , :i AQ 1 3 • ' .x .wt - U-1 Lf� i\ i. 00 P a, s UO MNVQn r , A • r,► ►A a N c,cc un m m i 0: 3 z t'I M eq V cv m m ri m i h MY no Y. �I UW 5 I i v YNIY 4 A I. I i. 1. i i1 iA i ♦ is g i E 3 i. i N N a a i i w m ^. i M w M VI v ul no fr � e: � "a �' f„,& •,k s .g '� m n'✓�'� ?' � e'-v`. � 4 -a ,� `W a� �� �� . �- a & '`, v: u 5 a ? A £ +Y , 5 r/ ■ - 1 E 4 ? .0 r H Y s`s ✓ . c yn Commonwealth ofassac usetts City/Town of SEC` ® " • System Pumping Recor JUL 3 12008 Form 4 , TOWN OF NORTH ANDOVER DEP has provided this form for use by local Boards of Health. Other for ma"e-0 edPA ii#!'�tbeT information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 CMR 15.351. A. Facility Information Important: When filling out 1. System Location: forms the computer,use only the tab key Address \� to move your MC)T A�d���� Q 0' ,g Lf Z_ cursor-do not use the return City/Town State Zip Code key. 2. System Owner: Name ldrA Address(if different from location) City/Town State Zip Code Gig - bS5 -3031 Telephone Number B. Pumping Record p 1. Date of Pumping Da _ I _Qo 2. Quantity Pumped: GalJEW ons 3. Type of system: ❑ Cesspool(s) YSeptic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes E2"'No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: Good 6. S stem Pumped By: 3 q 0,1 1�CosS M`OR — Name Vehicle License Number ' �(i<nc1 t��ye� •Enyiro��me��al Company 7. Location where contents were dis osed: si nature of Hauler Date In.ature of Receiving Facility Date t5form4.doc•03/06 System Pumping Record-Page 1 of 1 Commonwealth of Massachusetts r.4 City/Town of - System Pumping Record NORTH ANDOVCRForm 4 2010 DEP has provided this form for use by local Boards of Health. Other forms11111h�JDOVER information must be substantially the same as that provided here. Before u6WW ou local Board of Health to determine the form they use. The System Pumping Record must be submitted o the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 CMR 15.351. A. Facility Information Important: When filling out 1. System Location: 11 forms on the 66 5Lt'n S C hock computer,use --- — -- --...----/-----_ - only the tab key Address to move your -Vlnl r�j ovc'f cursor-do not _- . State Zip Code use the return City[Town key. 2. System Owner: -wL -Mat aha ti --- -- — -- - - Name — ---- �° Address(if different from location) City/Town --- —------ State ---- - Zip Code --"— q.76-66S- 3031_-__._ ---- Telephone Number B. Pumping Record 1. Date of Pumping 74- 1 0 2. Quantity Pumped: Gallons u Date 3. Type of system: ❑ Cesspool(s) (Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): --- ------ --- -----_— — -- 4. Effluent Tee Filter present? ❑ Yes [ No If yes, was it cleaned? ❑ Yes [O/No 5. Condition of System: 6. System Pumped By: Jim ------ N m Vehicle License Number Svc( Environtime;n Company 7. Location where contents were disposed: Treatm, eni Plaa-- Signature of Hauler �S��4� � Date ni. Signature of Receiving Facility Date t5form4.doc•03106 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts City/Town of NORTH ANDOVER MASSACHU ETi1DEIVED System Pumping Record Form 4 JUL 18 2006 TOWN OF'NO TH.AN O1', DEP has provided this form for use by local Boards of Health. The Syst m Raraip-tngE wr::!m-uu be submitted to the local Board of Health or other approving authority. A. Facility Information Important: When filling out 1. System Location: forms on the .computer,use only the tab key Address to move your V A (,t cursor-do not � — use the return City/Town State Zip Code key. 2 System Owner: Name Address(if different from location) — City/Town State 7 Zip Code 3r✓ r� b\J s— J l Telephone Number B. Pumping Record 1. Date of Pumping Dae 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) tic Tank ❑ Tight Tank ❑ Other(describe): — 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. System Pumped By: I&, s s Name Vehicle License Number Company 7. Location where contents were disposed: Siinature of Hauler Date ' http://www.mass.gov/dep/water/approvaIslt5forms.htm#inspect t5form4.doc•06/03 System Pumping Record•Page 1 of 1 LETTER OF TRANSMITTAL North Andover Health Department t NORTH 400 Osgood Street 3?p';�s�.eo .,6'�.I, North Andover, MA 01845 978.688.9540 -Phone - 978.688.8476- Fax �o ,.••" healthdent(7u townofnorthandover com - E-mail �qs�,,.o �►�''��•� www.townofnorthandover.com -Website Page / of SACNuSE To: _ DATE: �y COMPANY: > FROM:Pamela DelleChiaie,Health Dept.Assistant Phone: RE: Fax: We are sendin ou: OCoo Letter OPlans OOther 111 in below) These are transmitted as the below: OApproved as Noted Requested OAs Required OResubmit copies for.approval OFor approval OFor Review and comment OFor Your Use . OSubmit copies for dist. REMARKS- 917 ✓'O.l�L �'J G%� Com" COPY TO: COPY TO: COPY TO: SIGNED: CERTIFIED PLOT PLAN LOCATED IN NORTH ANDOVER, MASS. SCALE:1"=50' DATE:8/31/95 Scott L. Giles R.P.L.S. 50 Deer Meadow Road North Andover, Mass. NOTE:SEPTIC SYSTEM CERTIFIED 9/11/95 ELEVATIONS OUT OF HSE.=149.71 INTO TANK=149.25 OUT TANK =148.95 LOT #12 INTO D.B.=148.93 OUT D.B. =148.78 #1 =148.33 101-12 #3 =148.40 #4 =148.33 180.91 #4 R=60.00 #3 N L=100.00 10' #2 T.O.W.=155.38 40' #1 35' SUNSET ROCK 31.5, ROADco LOT #13 40,194 S.F. may PLAN#12,544 N.E.R.D. ik �tk.L •sy R LOT#14 o^. I CERTIFY THAT OFFSETS SHOWN ARE FOR THE USE Of THE OFFSETS OF THE BUILDING INSPECTOR ONLY SHOWN COMPLY AND SUCH USE IS FOR THE WITH THE ZONING LDETERMINATION OF ZONING . 13972 as BY LAWS OF f-/STEREo� NORTH ANDOVER CONFORMITY OR NON-CONFORMITY '°�a< <saog WHEN BUILT WHEN CONSTRUCTED. Form 4 -- System Pumping Record Commonwealth of Massachusetss : Massachusetts l System Pumping Record f' System Owner System Location :E:rrao Gr.>qor y rim ITY Homme I6 Sun.7,- t Fork Pd I .:o i-o t RocK &d :,r th h.nd,ivur MA. Qi R45 t :r th Andrvor iv. [iia 45 9781 12;,-6910 % 11�16} 725-6010 x Type: Emergency Routine Cesspool: No Yes Septic tank: No EDYes Date of Pumping: Quantity Pumped: 1 Salim i System Pumped By: Wind River EnWm n mta1, LLC Permit#: Contents transferred to: Contents Disposed at: Date:2( S O'er Pumper Signature: Condition of System/Other Comments Dep Approved Form - 12/07/95 C4 . RRIE ?OPU,,4.5Y5T off;Pu.9P1?1,RECORD SIIpx'l.lC z '()�I 014 i9'8�?74• ?'r2 49 Jtiin UN; " • iS�l1 jJV�•1.1J SYSTuV 0 6VNEP- a _^� .YSTEM LOC,STJON: Ir �C✓' V• / O s- 59 c DATE Or F >�• —D= 6 • GALLONS CESSPOOL: NOr- L. �-� SEP"I'IC SYSTE4\1 pLU'$J BY: CT BRIER 'IFpr - . : r C& bTt Iry SEk` CQ'�I' ENTS TRANSFERRwD TG; Id WU91: JEi � :L ..'0 XH HStiflda odS 31>itlhdS ti0aj CURRIER FO � —SYSTEM PUMPING RECON SEPTIC & DRAIN SERVICE 107 FOREST STREET MIDDLETON (978)774-2772 01949 e COMMONWEALTH OF MASSACHUSETTS MASSACHUSETTS SYSTEM PULM-PING.RECORD SYSTEM OWNER: SYSTEM LOCATION: Ffo vi YC4 fd 66 Sun Se-� 2a�1� �z S 3S- 1 DATE OF PUMPING: QUANTITY PUMPED: C) GALLONS CESSPOOL: NO ❑ YES ❑ SEPTIC TANK: NO ❑ YES �— SYSTEM PUMPED BY: CURRIER SEPTIC & D RAIN SERVICE CONTENTS TRANSFERRED TO: DATE: INSPECTOR: �Q r I �v FORM 4-SYSTEM PUMPING RECORD CU R SEPTIC & DRAIN SERVICE 107 FOREST STREET;MIDDLETON,MA 01949 (978)774-2772 COMMONWEALTH OF MASSACHUSETTS MASSACHUSETTS SYSTEM PUMPING RECORD SYSTEM OWNER: SYSTEM LOCATION: s eP(4-c�1 ..� oL4105�cr,t !t t' l 5/ L OF sulq sc-� oc% 1vrAN -11,- DATE OF PUMPING: IU QUANTITY PUMPED: S G D l GALLONS CESSPOOL: NO YES El SEPTIC TANK: NO YES SYSTEM PUMPED BY: CURRIER SEPTIC & DRAIN SERVICE CONTENTS TRANSFERRED TO: DATE: f U �� - ' INSPECTOR: CERTIFIED PLOT PLAN LOCATED IN NORTH ANDOVER, MASS. SCALE:1"=50' DATE:8/31/95 pii Scott L. Giles R.P.L.S. , 50 Deer Meadow Road ; North Andover, Mass. SEP LOT #12 101.12 180.91 R=60.00 N L=100.00 v SUNSET ROCK T.O.W.ELEV.=155.38 ROAD y r LOT #13 40,194 S.F. PLAN#12,544 N.E.R.D. D •6Q D LOT#14 o,N. I CERTIFY THAT OFFSETS SHOWN ARE FOR THE USE Of THE OFFSETS OF THE BUILDING INSPECTOR ONLY SHOWN COMPLY AND SUCH USE IS FOR THE N WITH THE ZONING DETERMINATION OF ZONING BY LAWS OF CONFORMITY OR NON-CONFORMITY �lY4t U�N4� NORTH ANDOVER WHEN BUILT WHEN CONSTRUCTED. ' 107 FOREST STREET FILE# 101900A 4 MIDDLETON,MA 01949 4978)774-7122 ENVIRONMENTAL CURRIER SOLUTIONS, CORP. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PROPERTY OWNER'S NAME: SERRAO PROPERTY ADDRESS: 66 SUNSET ROCK ROAD: NORTH ANDOVER, MA ADDRESS OF OWNER: SAME (IF DIFFERENT) DATE OF INSPECTION: OCTOBER 19. 2000 NAME OF INSPECTOR: THOMAS J. CHIGAS * THE PROFESSIONAL EXPERTS IN THE SEPTIC AND DRAIN INDUSTRY 107 FOREST STREET FILE# 101900A MIDDLETON,MA 01949 (978)774-7122 ENVIRONMENTAL SOLUTIONS, CORP. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION PROPERTY ADDRESS:66 SUNSET ROAD NAME OF OWNER: SERRAO NORTH ANDOVER,MA ADDRESS OF OWNER: SAME DATE OF INSPECTION: OCTOBER 19.2000 NAME OF INSPECTOR: (PLEASE PRINT)THOMAS CHIGAS COMPANY NAME: CURRIER ENVIRONMENTAL SOLUTIONS, CORP. MAILING ADDRESS: 107 FOREST STREET, MIDDLETON,MA 01949 TELEPHONE NUMBER: (978) 774-7122 CERTIFICATION STATEMENT 1 CERTIFY THAT I HAVE PERSONALLY INSPECTED THE SEWAGE DISPOSAL SYSTEM AT THIS ADDRESS AND THAT THE INFORMATION REPORTED BELOW IS TRUE,ACCURATE,AND COMPLETE AS OF THE TIME OF INSPECTION. THE INSPECTION WAS PREFORMED BASED ON MY TRAINING AND EXPERIENCE IN THE PROPER FUNCTION AND MAINTENANCE OF ON-SITE SEWAGE DISPOSAL SYSTEM. I AM A DEP SYSTEM APPROVED INSPECTOR PURSUANT TO SECTION 15.340 OF TITLE 5(310 CMR 15.000). THE SYSTEM: YES PASSES CONDITIONALLY PASSES NEEDS FURTHER EVALUATION BY THE LOCAL APPROVING AUTHORITY FAILS INSPECTOR'S SIGNATURE: DATE: OCTOBER 19;2000 THE SYSTEM INSPECTOR SHALL SUBMIT A COPY OF THIS INS CTION REPOR 0 THE APPROVING AUTHORITY(BOARD OF HEALTH OR DEP) WITHIN 30 DAYS OF COMPLETING THIS INSPECTION. IF THE SYSTEM IS A SHARED SYSTEM OR HAS A DESIGN FLOW OF 10,000 GPD OR GREATER,THE INSPECTOR AND THE SYSTEM OWNER SHALL SUBMIT THE REPORT TO THE APPROPRIATE REGIONAL OFFICE OF THE DEP. THE ORIGINAL SHOULD BE SENT TO THE SYSTEM OWNER AND COPIES SENT TO THE BUYER,IF APPLICABLE,AND THE APPROVING. NOTES AND COMMENTS: N/A ****THIS REPORT ONLY DESCRIBES CONDITIONS AT THE TIME OF INSPECTION AND UNDER THE CONDITIONS OF USE AT THAT TIME. THIS INSPECTION DOES NOT ADDRESS HOW THE SYSTEM WILL PERFORM IN THE FUTURE UNDER THE SAME OR DIFFERENT CONDITIONS OF USE. REVISED 6/15/2000 PAGE I OF 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUED) PROPERTY ADDRESS:66 SUNSET ROCK ROAD OWNER: SERRAO DATE OF INSPECTION:OCTOBER 19 2000 INSPECTION SUMMARY: CHECK A,B,C,D OR E/ALWAYS COMPLETE ALL OF SECTION D A. SYSTEM PASSES: YES I HAVE NOT FOUND ANY INFORMATION,WHICH INDICATES THAT ANY OF THE FAILURE CRITERIA DESCRIBED IN 310 CMR 15.303 OR 310 CMR 15.304 EXIST. ANY FAILURE CRITERIA NOT EVALUATED ARE INDICATED BELOW. COMMENTS: B. SYSTEM CONDITIONALLY PASSES: NO ONE OR MORE SYSTEM COMPONENTS AS DESCRIBED IN THE"CONDITIONAL PASS"SECTION NEED TO BE REPLACED OR REPAIRED. THE SYSTEM,UPON COMPLETION OF THE REPLACEMENT OR REPAIR,AS APPROVED BY THE BOARD OF HEALTH,WILL PASS. ANSWER YES,NO,OR NOT DETERMINED(Y,N,OR ND)IN THE FOR THE FOLLOWING STATEMENTS. IF"NOT DETERMINED,"PLEASE EXPLAIN. N THE SEPTIC TANK IS METAL AND OVER 20 YEARS OLD OR THE SEPTIC TANK(WEATHER METAL OR NOT)IS STRUCTURALLY UNSOUND,EXHIBITS SUBSTANTIAL INFILTRATION OR EXFILTRATION,OR TANK FAILURE IS IMMINENT. SYSTEM WILL PASS INSPECTION IF THE EXISTING TANK IS REPLACED WITH A COMPLYING SEPTIC TANK AS APPROVED BY THE BOARD OF HEALTH. A METAL SEPTIC TANK WILL PAS INSPECTION IF IT IS STRUCTURALLY SOUND,NOT LEAKING AND IF A CERTIFICATE OF COMPLIANCE INDICATING THAT THE TANK IS LESS THAN 20 YEARS OLD IS AVAILABLE. ND EXPLAIN: N OBSERVATION SEWAGE BACKUP OR BREAKOUT OR HIGH STATIC WATER LEVEL IN THE DISTRIBUTION BOX IS DUE TO BROKEN OR OBSTRUCTED PIPE(S)OR DUE TO A BROKEN,SETTLED OR UNEVEN DISTRIBUTION BOX. SYSTEM WILL PASS INSPECTION IF(WITH APPROVAL OF THE BOARD OF HEALTH). N BROKEN PIPE(S)ARE REPLACED N OBSTRUCTION IS REMOVED N DISTRIBUTION BOX IS LEVELED OR REPLACED ND EXPLAIN: N THE SYSTEM REQUIRED PUMPING MORE THAN FOUR TIMES A YEAR DUE TO BROKEN OR OBSTRUCTED PIPE(S). THE SYSTEM WILL PASS INSPECTION IF(WITH APPROVAL OF THE BOARD OF HEALTH): N BROKEN PIPE(S)ARE REPLACED N OBSTRUCTION IS REMOVED REVISED 6/15/2000 PAGE 2 OF 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUED) PROPERTY ADDRESS:66 SUNSET ROCK ROAD OWNER: SERRAO DATE OF INSPECTION:OCTOBER 19,2000 C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: NO CONDITIONS EXIST WHICH REQUIRE FURTHER EVALUATION BY THE BOARD OF HEALTH IN ORDER TO DETERMINE IF THE SYSTEM IS FAILING TO PROTECT THE PUBLIC HEALTH, SAFETY,AND THE ENVIRONMENT. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303 (1)(B) THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: N/A CESSPOOL OR PRIVY IS WITHIN 50 FEET OF SURFACE WATER N/A CESSPOOL OR PRIVY IS WITHIN 50 FEET OF A BORDERING VEGETATED WETLAND OR A SALT MARSH. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER, IF ANY)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH, SAFETY AND ENVIRONMENT: N THE SYSTEM HAS A SEPTIC TANK AND SOIL ABSORPTION SYSTEM(SAS)AND THE SAS IS WITHIN 100 FEET OF A SURFACE WATER SUPPLY OR TRIBUTARY TO A SURFACE WATER SUPPLY. N THE SYSTEM HAS A SEPTIC TANK AND SAS AND THE SAS IS WITHIN A ZONE I OF PUBLIC WATER SUPPLY. N THE SYSTEM HAS A SEPTIC TANK AND SAS AND THE SAS IS WITHIN 50 FEET OF A PRIVATE WATER SUPPLY WELL. N THE SYSTEM HAS A SEPTIC TANK AND SAS AND THE SAS IS LESS THAN 100 FEET BUT 50 FEET MORE FROM A PRIVATE WATER SUPPLY WELL. METHOD USED TO DETERMINED DISTANCE THIS SYSTEM PASSES IF THE WELL WATER ANALYSIS,PERFORMED AT THE DEP CERTIFIED LABORATORY,FOR COLIFORM BACTERIA AND VOLATILE ORGANIC COMPOUNDS INDICATES THAT THE WELL IS FREE FROM POLLUTION FROM THAT FACILITY AND THE PRESENCE OF AMMONIA NITROGEN AND NITRATE NITROGEN IS EQUAL TO OR LESS THAN 5 PPM,PROVIDED THAT NO OTHER FAILURE CRITERIA ARE TRIGGERED. A COPY OF THE ANALYSIS MUST BE ATTACHED TO THIS FORM. 3) OTHER: N/A REVISED 6/15/2000 PAGE 3 OF 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUED) PROPERTY ADDRESS:66 SUNSET ROCK ROAD OWNER: SERRAO DATE OF INSPECTION:OCTOBER 19.2000 D. SYSTEM FAILURE CRITERIA APPLICABLE TO ALL SYSTEMS: YOU MUST INDICATE"YES"OR"NO"TO EACH OF THE FOLLOWING FOR ALL INSPECTIONS: YES NO NO BACKUP OF SEWAGE INTO FACILITY OR SYSTEM COMPONENT DUE TO AN OVERLOADED OR CLOGGED SAS OR CESSPOOL. NO DISCHARGE OR PONDING OF EFFLUENT TO THE SURFACE OF THE GROUND OR SURFACE WATERS DUE TO AN OVERLOADED OR CLOGGED SAS OR CESSPOOL. NO STATIC LIQUID LEVEL IN THE DISTRIBUTION BOX ABOVE OUTLET INVERT DUE TO AN OVERLOADED OR CLOGGED SAS OR CESSPOOL. N/A LIQUID DEPTH IN CESSPOOL IS LESS THAN 6'BELOW INVERT OR AVAILABLE VOLUME IS LESS THAN%DAY FLOW. N REQUIRED PUMPING MORE THAN 4 TIMES IN THE LAST YEAR NOT DUE TO CLOGGED OR OBSTRUCTED PIPE (S). NUMBER OF TIMES PUMPED N ANY PORTION OF THE SAS,CESSPOOL OR PRIVY IS BELOW THE HIGH GROUND WATER ELEVATION. N/A ANY PORTION OF A CESSPOOL OR PRIVY IS WITHIN 100 FEET OF A SURFACE WATER SUPPLY OR TRIBUTARY TO A SURFACE WATER SUPPLY. N/A ANY PORTION OF A CESSPOOL OR PRIVY IS WITHIN A ZONE I OF A PUBLIC WELL. N/A ANY PORTION OF A CESSPOOL OR PRIVY IS WITHIN 50 FEET OF A PRIVATE WATER SUPPLY WELL. N/A ANY PORTION OF A CESSPOOL OR PRIVY IS LESS THAN 100 FEET BUT GREATER THAN 50 FEET FROM A PRIVATE WATER SUPPLY WELL WITH NO ACCEPTABLE WATER QUALITY ANALYSIS. [THIS SYSTEM PASSES IF THE WELL WATER ANALYSIS,PERFORMED AT A DEP CERTIFIED LABORATORY,FOR COLIFORM BACTERIA AND VOLATILE ORGANIC COMPOUNDS INDICATES THAT THE WELL IS FREE FROM POLLUTION FROM THAT FACILITY AND THE PRESENCE OF AMMONIA NITROGEN AND NITRATE NITROGEN IS EQUAL TO OR LESS THAT 5 PPM,PROVIDED THAT NO OTHER FAILURE CRITERIA ARE TRIGGERED. A COPY OF THE ANALYSIS MIST BE ATTACHED TO THIS FORM.] NO (YES/NO)THE SYSTEM FAILS. I HAVE DETERMINED THAT ONE OR MORE OF THE ABOVE FAILURE CRITERIA EXIST AS DESCRIBED IN 310 CMR 15.303,THEREFORE THE SYSTEM FAILS. THE SYSTEM OWNER SHOULD CONTACT THE BOARD OF HEALTH TO DETERMINE WHAT WILL BE NECESSARY TO CORRECT THE FAILURE. E. LARGE SYSTEMS: BE CONSIDERED A LARGE SYSTEM THE SYSTEM MUST SERVE A FACILITY WITH A DESIGN FLOW OF 10,000 GPD TO 15,00 D. YOU MUS ICATES EITHER"YES"OR"NO"TO EACH OF THE FOLLOWING: (THE FOLLOWI CRITERIA APPLY TO LARGE SYSTEMS IN ADDITION TO THE CRITERIA VE) NO THE SYSTEM SE S A FACILITY WITH A DESIGN FLOW OF 10,000 GP GREATER(LARGE SYSTEM)AND THE SYSTEM IS A SIGNIFICANT TH T TO PUBLIC HEALTH AND SAFETY A HE ENVIRONMENT BECAUSE ONE OR MORE OF THE FOLLOWING CONDITIONS EXI YES NO THE SYSTEM IS WITHIN 400 FEE SURFACE DRINKING WATER SUPPLY THE SYSTEM IS WITHIN EET OF A T TARY TO A SURFACE DRINKING WATER SUPPLY THE SYSTEM IS LO D IN A NITROGEN SE IVE AREA(INTERIM WELLHEAD PROTECTION AREA-IWPA) OR A MAPPED ZONE I A PUBLIC WATER SUPPLY WELL IF YOU HAVE ANS D "YES"TO ANY QUESTION IN SECTION E THE SYST S CONSIDERED A SIGNIFICANT THREAT, OR ANSWERED " " IN SECTION D ABOVE THE LARGE SYSTEM HAS FAILED. T WNER OR OPERATOR OF ANY LARGE SYSTE NSIDERED A SIGNIFICANT THREAT UNDER SECTION E OR FAILED UND ECTION D SHALL UPGRADE THE S M IN ACCORDANCE WITH 310 CMR 15.304. THE SYSTEM OWNER SHOULD CONTA THE APPROPRIATE REGIONAL OFFICE OF THE DEPARTMENT. REVISED 6/15/00 PAGE 4 OF 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST PROPERTY ADDRESS:66 SUNSET ROCK ROAD OWNER: SERRAO DATE OF INSPECTION:OCTOBER 19.2000 CHECK IF THE FOLLOWING HAVE BEEN DONE. YOU MUST INDICATE"YES"OR"NO"AS TO EACH OF THE FOLLOWING: YES NO YES PUMPING INFORMATION WAS PROVIDED BY THE OWNER, OCCUPANT, OR BOARD OF I HEALTH. NO WERE ANY OF THE SYSTEM COMPONENTS PUMPED OUT IN THE PREVIOUS TWO WEEKS? YES HAS THE SYSTEM RECEIVED NORMAL FLOWS IN THE PREVIOUS TWO WEEK PERIOD? NO HAVE LARGE VOLUMES OF WATER BEEN INTRODUCED TO THE SYSTEM RECENTLY OR AS PART OF THIS INSPECTION? YES WERE AS BUILT PLANS OF THE SYSTEM OBTAINED AND EXAMINED? (IF THEY WERE NOT AVAILABLE NOTE AS N/A) YES WAS THE FACILITY OR DWELLING INSPECTED FOR SIGNS OF SEWAGE BACK UP? YES WAS THE SITE INSPECTED FOR SIGNS OF BREAK OUT? YES WERE ALL SYSTEM COMPONENTS,EXCLUDING THE SAS,LOCATED ON SITE? YES WERE THE SEPTIC TANK MANHOLES UNCOVERED, OPENED,AND THE INTERIOR OF THE TANK INSPECTED FOR THE CONDITION OF THE BAFFLES OR TEES,MATERIAL OF CONSTRUCTION,DIMENSIONS,DEPTH OF LIQUID,DEPTH OF SLUDGE AND DEPTH OF SCUM? YES WAS THE FACILITY OWNER(AND OCCUPANTS IF DIFFERENT FROM OWNER)PROVIDED WITH INFORMATION ON THE PROPER MAINTENANCE OF SUBSURFACE SEWAGE DISPOSAL SYSTEMS? THE SIZE AND LOCATION OF THE SOIL ABSORPTION SYSTEM(SAS) ON THE SITE HAS BEEN DETERMINED BASED ON: EXPOSING SYSTEM AND USE OF TRANSMITTER. YES NO NO EXISTING INFORMATION. FOR EXAMPLE,A PLAN AT THE BOARD OF HEALTH. NO DETERMINED IN THE FIELD(IF ANY OF THE FAILURE CRITERIA RELATED TO PART C IS AT ISSUE,APPROXIMATION OF DISTANCE IS UNACCEPTABLE) [3 10 CMR 15.302(3)(b)] REVISED 6/15/2000 PAGE 5 OF 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION PROPERTY ADDRESS:66 SUNSET ROCK ROAD OWNER: SERRAO DATE OF INSPECTION:OCTOBER 19.2000 FLOW CONDITIONS I RESIDENTIAL: NUMBER OF BEDROOMS(DESIGN):4 NUMBER OF BEDROOMS(ACTUAL):4 i DESIGN FLOW BASED ON 310 CMR 15.203 (FOR EXAMPLE: 110 GPD X#OF BEDROOMS):440 I NUMBER OF CURRENT RESIDENTS:4 I DOES RESIDENCE HAVE A GARBAGE GRINDER(YES OR NO):NO IS LAUNDRY ON A SEPARATE SEWAGE SYSTEM(YES OR NO):NO[IF YES SEPARATE INSPECTION REQUIRED] LAUNDRY SYSTEM INSPECTED(YES OR NO):N/A SEASONAL USE(YES OR NO):NO WATER METER READINGS,IF AVAILABLE(LAST 2 YEARS USAGE(GPD)): 575,212 GALSS FOR 2 YEARS SUMP PUMP(YES OR NO):NO LAST DATE OF OCCUPANCY: CURRENT COMMERCIAL/INDUSTRIAL: E OF ESTABLISHMENT: DE FLOW(BASED ON 310 CMR 15.20 GPD BASIS 0 SIGN FLOW(SEATS/PE S/SQ.FT,ETC.): GREASE TRA SENT(YES O O): INDUSTRIAL WAS OL G TANK PRESENT(YES OR NO): NON-SANITARY WAS SCHARGED TO THE TITLE 5 SYSTEM(YES OR NO): WATER METER DINGS, VAILABLE: LAST DATE OCCUPANCY/US 0 R(DESCRIBE): GENERAL INFORMATION PUMPING RECORDS SOURCE OF INFORMATION:OWNER WAS SYSTEM PUMPED AS PART OF INSPECTION(YES OR NO):YES IF YES,VOLUME PUMPED: 1500 GALLONS-HOW WAS QUANTITY PUMPED DETERMINED? THE SIZE OF TANK. REASON FOR PUMPING:INSPECTION TYPE OF SYSTEM YES SEPTIC TANK,DISTRIBUTION BOX,SOIL ABSORPTION SYSTEM N SINGLE CESSPOOL N OVERFLOW CESSPOOL N PRIVY N SHARED SYSTEM(YES OR NO)(IF YES,ATTACH PREVIOUS INSPECTION RECORDS,IF ANY) N INNOVATIVE/ALTERNATIVE TECHNOLOGY. ATTACH A COPY OF THE CURRENT OPERATION AND MAINTENANCE CONTRACT(TO BE OBTAINED FROM SYSTEM OWNER) N TIGHT TANK ATTACH A COPY OF THE DEP APPROVAL N/A OTHER(DESCRIBE): APPROXIMATE AGE OF ALL COMPONENTS,DATE INSTALLED(IF KNOWN)AND SOURCE OF INFORMATION: INSTALLED TANK IN 1996. OWNER AND AS BUILT WERE SEWAGE ODORS DETECTED WHEN ARRIVING AT THE SITE(YES OR NO):NO REVISED 6/15/2000 PAGE 6 OF 11 SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM PART C SYSTEM INFORMATION(CONTINUED) PROPERTY ADDRESS:66 SUNSET ROCK ROAD OWNER: SERRAO DATE OF INSPECTION:OCTOBER 19.2000 BUILDING SEWER(LOCATE ON THE SITE PLAN) DEPTH BELOW GRADE:4'9" MATERIAL OF CONSTRUCTION:YES CAST IRON 40 PVC OTHER(EXPLAIN) ; DISTANCE FROM PRIVATE WATER SUPPLY WELL OR SUCTION LINE:N/A COMMENTS: (CONDITION OF JOINTS,VENTING,EVIDENCE OF LEAKAGE,ETC.) THERE WERE NO SIGNS OF LEAKAGE IN OR AROUND PIPE.SOILS WERE CLEAN AND DRY SEPTIC TANK: YES (LOCATE ON SITE PLAN) DEPTH BELOW GRADE:4' MATERIAL OF CONSTRUCTION:YESCONCRETE METAL FIBERGLASS POLYETHYLENE OTHER (EXPLAIN): IF TANK IS METAL,LIST AGE IS AGE CONFIRMED BY A CERTIFICATE OF COMPLIANCE(YES OR NO) (ATTACH A COPY OF CERTIFICATE) DIMENSIONS: 101 X 5'W X 5'H OUTLET INVERT @ 4'2" = 1500 GAL SLUDGE DEPTH: 12" DISTANCE FROM TOP OF SLUDGE TO BOTTOM OF OUTLET TEE OR BAFFLE: 26" SCUM THICKNESS: <4" DISTANCE FROM TOP OF SCUM TO TOP OF OUTLET TEE OR BAFFLE: 5" DISTANCE FROM BOTTOM OF SCUM TO BOTTOM OF OUTLET TEE OR BAFFLE: 10" HOW WERE DIMENSIONS DETERMINED: SLUDGE JUDGE,ROD.RULER COMMENTS(ON PUMPING RECOMMENDATION,INLET AND OUTLET TEES OR BAFFLES CONDITION,STRUCTURAL INTEGRITY,LIQUID LEVEL AS RELATED TO OUTLET INVERT,EVIDENCE OF LEAKAGE,ETC.):THE TANK WAS PUMPEDJHE LIQUID LEVEL WAS AT NORMAL HIGHT.NO SIGNS OF LEAKAGE THE INLET AND OUTLET BAFFLES ARE PVC AND THERE IN GOOD CONDITION.THE INTEGRITY OF THE TANK IS FINE.THE SOILS ARE CLEAN AND DRY.THERE IS A 4'EXTENSION ON THE MIDDLE COVER. GREASE TRAP: NO (LOCATE ON SITE PLAN) DEPT OW GRADE: MATERIAL OF TRUCTION: CONCRETE METAL FIB SS POLYETHYLENE OTHER (EXPLAIN) DIMENSIONS: SCUM THICKNESS: DISTANCE FROM TOP OF SCUM TO TOP T EE OR BAFFLE: DISTANCE FROM BOTTOM OF S 0 BOTTOM OF 0 TEE OR BAFFLE: DATE OF LAST PUMPIN COMMENTS(ON ING RECOMMENDATION,INLET AND OUTLET TE BAFFLES CONDITION,STRUCTURAL INTEGRI , QUID LEVEL AS RELATED TO OUTLET INVERT,EVIDENCE OF LEA ETC.): REVISED 6/15/200 PAGE 7 OF 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(CONTINUED) PROPERTY ADDRESS:66 SUNSET ROCK ROAD OWNER:SERRAO DATE OF INSPECTION:OCTOBER 19,2000 TIGHT OR HOLDING TANK:NO(TANK MUST BE PUMPED AT TI F INSPECTION)(LOCATE ON SITE DEPTH BELO E: MATERIAL OF CONST TION: CONC METAL FIBERGLASS POLYETHYLENE OTHER (EXPLAIN) DIMENSIONS: CAPACITY: GALLONS DESIGN FLOW: G ONS/DAY ALARM PRESENT OR NO): ALARM LEVE • ALARM IN WORKING ORDER( R NO): DATE OF T PUMPING: CO S (CONDITION OF ALARM AND FLOAT SWITCHES,ET . . DISTRIBUTION BOX: YES(IF PRESENT MUST BE OPENED) (LOCATE ON SITE PLAN) DEPTH OF LIQUID LEVEL ABOVE OUTLET INVERT: 0" DEPTH BELOW GRADE: 4'5" COMMENTS (NOTE IF BOX IS LEVEL AND DISTRIBUTION TO OUTLET EQUAL,ANY EVIDENCE OF SOLIDS CARRYOVER,ANY EVIDENCE OF LEAKAGE INTO OR OUT OF BOX,ETC.): THERE IS NO SIGNS OF LEAKAGE IN OR AROUND BOX, SOILS ARE CLEAN AND DRY THERE'S NO SIGNS OF HYDRAULIC FAILURE IN OR OUT.THERE'S ONE INLET SCH 40 PVC AND FOUR OUTLETS ORENGEBERG CONSTRUCTION,ALL IN GOOD CONDITION THE SOILS ON TOP OF SYSTEM IS A CLAYISH SOIL AND THERE TIGHT. PUMP CHAMBER:NO (LOCATE ON SITE PLAN) PUMPS IN WO RI R(YES O ALARMS IN WORKING ORD NO): COMMENTS (NOTE ITIONS OF PUMP CONDITION OF PUMPS AND APPURTENANCES, ETC.): REVISED 6/15/2000 PAGE 8 OF 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(CONTINUED) PROPERTY ADDRESS:66 SUNSET ROCK ROAD OWNER: SERRAO DATE OF INSPECTION:OCTOBER 19,2000 SOIL ABSORPTION SYSTEM(SAS): YES(LOCATE ON SITE PLAN,EXCAVATION NOT REQUIRED) IF SAS NOT LOCATED EXPLAIN WHY: TYPE: LEACHING PITS,NUMBER: LEACHING CHAMBERS,NUMBER: LEACHING GALLERIES,NUMBER: LEACHING TRENCHES,NUMBER,LENGTH:FOUR LINES.TRENCHES LEACHING FIELDS,NUMBER,DIMENSIONS: OVERFLOW CESSPOOL,NUMBER: INNOVATIVE/ALTERNATIVE SYSTEM TYPE OF TECHNOLOGY: COMMENTS(NOTE CONDITION OF SOIL, SIGNS OF HYDRAULIC FAILURE,LEVEL OF PONDING,DAMP SOIL, CONDITION OF VEGETATION,ETC.) THERE WAS NO SIGNS OF FAILURE OR POOLING IN LINES THE SOILS AROUND AREA ARE CLEAN AND DRY THERE WAS NO SIGNS OF BRAKOUTS OR WETLAND VEGETATION IN OR AROUND SYSTEM THE SOILS ON TOP OF SYSTEM ARE CLAYISH BUT DRY. CESSPOOLS: NO(CESSPOOL MUST BE PUMPED AS P F INSPECTION) (LOCATE ON SITE PLAN NUM ND CONFIGURATION: DEPTH-TOP IQUID TO INLET INVERT: DEPTH OF SOLID L DEPTH OF SCUM LAYER: DIMENSIONS OF CESSPOOL: MATERIALS OF CONST TION: INDICATION OF G WATER INFLOW(YE 0): COMMENTS TE CONDITION OF SOIL,SIGNS OF ULIC FAILURE,LEVEL OF PONDING,CONDITION OF VEGET ON,ETC.): RIVY: NO(LOCATE ON SITE PLAN MATERIAL CONSTRUCTION DIMENSIONS: DEPTH SOLIDS: COMMENTS(NO ONDITION O SIGNS�OF HYDRAULIC FAILURE,LEVEL OF PONDING,CONDITION OF VEGETATI TC.): REVISED 6/15/00 PAGE 9 OF 11 t r PART C SYSTEM INb gqr�ff '&ED) PROP RTY ADDRESS:66 SUNSET ROAD LOCATED IN NORTH ANDOVER, MASS. OWN R:SERRAO SCALER"=50' DATE:8/31/95 DATE OF INSPECTION:OCTOBER 19 2000 SKETCH OF SEWA4UILDING. SAL SYSTEM: Scott L. Giles R.P.L.S. PRO IDE A SKETCH AGE DISPOSAL SWjb9B# bp�QTIES TO AT LEAST TWO PERMANENT REFE NCE LANDMANCHMARKS. LOQ6jWA4&yg 100 FEET. LOCATE WHERE PUBLIC WAT R SUPPLY ENTE NOTE:SEPTIC SYSTEM CERTIFIED 9111/95 ELEVATIONS OUT OF HSE.=149.71 INTO TANK=149.25 OUT TANK =148.95 LOT #12 INTO D.B.=148.93 OUT D.B. =148.78 #1 =148.33 101.12 #3 =148.40 #4 =148.33 180.91 R=60.00 #3 +' <V L=100.00 a T. .W.=155.38 SUNSET ROCK #1 35 ROAD > ko LOT#13 40,194 S.F. PLAN#12,544 N.E.R.D. Dk A LOT#14 a I CERTIFY THAT OFFSETS SHOWN ARE FOR THE USE ���H OF THE OFFSETS OF THE BUILDING INSPECTOR ONLY G SHOWN COMPLY AND SUCH USE IS FOR THE WITH THE ZONING L DETERMINATION OF ZONING o, • 13872 {o BY LAWS OF f�►STERE� NORTH ANDOVER CONFORMITY OR NON-CONFORMITY %SIL `kit WHEN BUILT WHEN CONSTRUCTED. REVISED 6/15/2000 PAGE 10 OF 11 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(CONTINUED) PROPERTY ADDRESS:66 SUNSET ROCK ROAD OWNER: SERRAO DATE OF INSPECTION:OCTOBER 19,2000 SITE EXAM SLOPE -THERE IS A SLIGHT SLOPE IN BACK YARD. SURFACE WATER-NONE CHECK CELLAR -THERE WAS NO SIGNS OF WATER INFILTRATION IN BASEMENT. SHALLOW WELLS -NONE ESTIMATED DEPTH TO GROUNDWATER 8'+APPROX FEET PLEASE INDICATE(CHECK)ALL THE METHODS USED TO DETERMINE HIGH GROUNDWATER ELEVATION: YES OBTAINED FROM SYSTEM DESIGN PLANS ON RECORD-IF CHECKED,DATE OF DESIGN PLAN REVIEWED: YES OBSERVED SITE(ABUTTING PROPERTY/OBSERVATION HOLE WITHIN 150 FEET OF SAS) NO CHECKED WITH LOCAL BOARD OF HEALTH-EXPLAIN: NO CHECKED LOCAL EXCAVATORS,INSTALLERS-(ATTACH DOCUMENTATION) YES ACCESSED USGS DATABASE-EXPLAIN: MAPS YOU MUST DESCRIBE HOW YOU ESTABLISHED THE HIGH GROUND WATER ELEVATION: THE HOUSE DOESN'T HAVE A SUMP PUMP AND THE BASEMENT IS DRY.WHILE DIGGING IN YARD THERE WASN'T ANY SIGNS OF WATER TABLE OR WETLAND VEGETATION IN OR NEAR SYSTEM.THERE'S NO ABBUTTING PROPERTY'S WELLS OR WETLANDS WITHIN 100'FROM SYSTEM. REVISED 6/15/2000 PAGE l I OF 11 •r� � 1 r.y;,r�.n V '• dn�til,; .".:�:: .., '�'',f,•� ;t.,.�i a'/' •�iy:;li��;•/r;. :'��� .� + ORT �A�1D•OVER� MAS •` ... �::�• r, . . SACHUSETTS . . 'S + tle ml-r record ;'� ,11�..'',' . :ir�.•,j�.(y�� • A ,�,�j+`t;�y�rt;��j.y��{�' ��'�lrli:l.!r.:�:. .. .I•. t'lr,rt VY'�`�il::'• ��y��+�'1 rlC�Ir1i.;�, t. 1 !.i�,t,,,,t,tji-r• � tu1,,,ta+r'rl• ''•'•!•�.y, }•,•V'Ir. t',.?� .r,., •` pEP.,has roolded vf' ittla.form for use by local Boards of Health, The System Pumping Recoic be submlted to tha,local'Board of Health or other :>,.. ,,' r: :w.;•c:rr +;;:,c;.:.,c;r•. aPProvins authority. .A Faclilty .lnforritlon .out .1.. System Locatloni� onty the tab keyr Address to move your:, cursor:•do not ' �. us+'th�tetum. ;,; ;.CltyRown r-... •,: Slat ,`�,i,•L.y, .,��•wili+i�':i7Y'•�'.).'''::.'{':t•)i!''gq! �;r+1'�.��,1:;::1:,�• .. a uP p j,v.. 1��Y7r,:4A(,',• .i •i. It. ,t'. Code •,i tt�a .� SlIJ"i'•1•iGi S ,stem owner ' •'Ft•••J' '� la .IY::vr.;!•�.,. .r'.t•,..,..,r.fir.'• •.et.• Name 44, 'Address(If different trom'IocgUon) �;�,� ' :i':Cttyri'own:•°.� :,;�:,ie•.,;.'•; ;,:': . State Tolephone Number � ",rl:.t ..11�. .qtr•I�%' Y."':.l� .. ., ' t ; ,P,umpjng:Re. ord; '!�'i: i�,�:�7 .err,:i/t.:5>/Iv:r}iii:�'fir•!•',..7�i(It��:.�1i�!��f1�t,l;•It•r:.• 'r. `` •�'11, .Date of Pumpin9'tr' t' Date 2.'Qu ntJty Pumped: t: .. ;,3,: 'Type pf:aystam;; [] Cesspools) Se tic Tank • h': : :�.,:',;,::t: p ❑ Tight Tank 'Other(desod ~�4,V"°:Effluent Tee FIIte y a ed7 { resent?.❑ Yes ❑ No If p' es, was it clean ❑ Yes ❑ No . . :..i'�•' .'•rg;��,1,�. ,l'9.r:� t •!•ri'j� iNt�:�(;;ly'� �;�'• . .. .;is •: ,;, ,,1qr a N•,l��.r. ' •.I;j.. .F. y t',ti Si•, jjfei Ilte�! r:t' t o r i �'ffllS�I/lr'1/I J .I.w.'P•�i!oN J. r:• '.ti�.: i` �+�' �/ ' .1�'�•t ►lyhal!i{f/Y.il4r;1:;%/��i!'y'r,`,1�:�fyJ'1:,j�,,` ,�:;.•.•;�•. .. � i .. 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Date :haFJ/wtivw:mass'gov/dep�wafer/approvaJs/t6(orms,htm#Inspect t5forrM.doa�t�IQ3 r� '•;` ;•t� SyCam Pumpin9 Record Pip t { t (' ....-. fit ,. . � ORT O O ? / dover NY711I" ° }� ; i rt dover, Mass., Zot O �- LAKE � COCMI C.E W ICK \1 a A DR TED PPt �� BOARD OF HEALTH 1 4 Food/Kitchen PERMIT T D Septic System BUILDING INSPECTOR mAekRAV_ ..................................... . THIS CERTIFIES THAT..................................................................................::.......................................... Foundation .............................. g �o�►.....4� 1 �� ............ ........ .. 13 I has permission to erect.` ....RAMP buildings Rei � to be occupied as v Aaa....'FAQAL .X �4�.1 6...... ��+►..... .......................... Chimney provided that the person accepting this per it shall in every respect onform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the InspeNtpbaRtindp$kftr8ky of Buildings in the Town of North Andover. "TOR PLUMBINGI REGULATED BY PARA. 114.8-S. B.C. po��oar�KC "u/� VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough��� Se'�'` /'�� FEE PAID Fin y�at( �C PERMIT EXP 6 MO S S� (CE//Ljh)'ECTRIC PECTOR ou `� l��T3 UNLESS C_ ONS ;� tRAME/BUILDING ... . .......... ...... .............. ......... .............. .. ervice PER�111:f . ... .. .. . S . BUILDING INSPECTOR DATE: FEE PAID: fAS INSPECTOR Occupancy Permit Required to Occupy Building �a 4 , D A Conspicuous Place on the Premises — Do Not Remove Rn gh �' C_'0q.I" '"' Display in a p adys No Lathing or Dry Wall To Be. Done FIRE DEPAI&MENT Until Inspected and Approved by the Building Inspector. Burner Street No. PLANNING CONSERVATION ,r 'Z Smoke Det. �g n JZY,{� Irl./rr� /\./ATrPY riklAi MIX/MNAV PKITPV PERMIT J FORM U - IAT RETJ?ASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable local or state law, regulations or requirements. ****************Applicant fills out this section***************** APPLICANT: J - Phone LOCATION: Assessor's Map Number Parcel Subdivision L Lot(s) Street St. Number ************************Official Use Only************************ RECOMMENDATIONS OF TOWN AGENTS: Conservation Administrator Date Approved Date Rejected Comments Town Planner Date Approved Date Rejected Comments Food Inspector-Health Date Approved Date Refected Date Approved -71�/ Septic Inspector-Health pp Date Rejected Comments Public Works - sewer/water connections - driveway permit Fire Department Received by Building Inspector Date Town of North Andover, Massachusetts Form No.3 NORTH BOARD OF HEALTH 1 --1 '1'...o ;,.tioo 9 3 _ � f 9 �'-�,,,;;:•�"� DISPOSAL WORKS CONSTRUCTION PERMIT �SS<1CHUS�S Applicant �/ CC'S GGG �J c� TELEPHONE NAME // ADDRESS Site Location Permission is hereby granted to Construct or Repair ( ) an Individual Soil Absorption Sewage Disposal System as shown on the Design Approval S.S. No. CHAIRMAN,BOARD OF HEALTH Fee D.W.C. No. s 1 Town of North Andover, Massachusetts f3 F°""«o.s BOARD OF HEALTH r - 193 ~ s I ss DESIGN APPROVAL FOR �ssAcim SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM Applicant Test No . � r Site Location fi C-x Reference Plans and Specs. , ENGINEER DESIGN DATE s+ tt Permission is granted for an individual soil absorption sewage disposal system to be installed a in accordance with regulations of Board of Health. CHAIRMAN,BOARD OF HEALTH Fee Site System Permit No. /� I p10R TIS BOARD OF HEALTH O 9 t s c° 120 MAIN STREET TEL. 682-6483 NORTH ANDOVER, MASS. 01845 Ext23 9SSACHUSEt 6PLC January 19, 1995 Neve Associates 447 Old Boston Road Topsfield, MA 01983 Re: Lot #13 Sunset Rock Road Dear Tom: I This is to inform you that the proposed plans for site referenced above have been disapproved for the following reasons: i 1) What is the elevation of catch basin? 2) What is the elevation of P12 done in 1987? 3) Perc 93-14 is not 4 feet below bottom of system. If you have any questions, please do not hesitate to call the Board of Health Office at the number above. Sincerely, ` Sandra Starr, R.S. I Health Administrator SS/cjp i 40PTrl ?0 °Z. BOARD OF HEALTH N p t • 120 MAIN STREET TEL. 682-6483 SS„c,,,,SEt�y NORTH ANDOVER, MASS. 01845 Exc23 January 19, 1995 Neve Associates 447 Old Boston Road Topsfield, MA 01983 Re: Lot #13 Sunset Rock Road Dear Tom: This is to inform you that the proposed plans for site referenced above have been disapproved for the following reasons: 1) What is the elevation of catch basin? 2) What is the elevation of P12 done in 1987? 3) Perc 93-14 is not 4 feet below bottom of system. If you have any questions, please do not hesitate to call the Board of Health Office at the number above. Sincerely_,-_ Sandra Starr, R.S. Health Administrator SS/cjp / o f DATE / Sheet BOARD OF HEALTH TOWN OF NORTH ANDOVER SUBSURFACE DISPOSAL DESIGN REVIEW PERMIT DATE RECEIVED FEE - PE ------ APPLICANT lBO8 J,4jZf6Z,- ASSESSOR' S MAP ADDRESS PARCEL 4 LOT ? / 3 STREET 5UA)5tFT 720G,(- ENGTI EER T 4EII ADDRESS PLAN DATE ��C /gCf� REVISION DATE CONDITIONS OF APPROVAL: J G APPRO"ED DIS:PPRO`JED 3 - �OT -P&-ie PLAN RREVIEW CHECKLIST n/ ADDRESS /3 c�U�SLT% K 1`17 ENGINEER TOM /V G(/E GENERAL / / / 3 COPIES ✓ STAMPy LOCUS z/ NORTH ARROW �- SCALE CONTOURSI,:,,,- PROFILE SECTION BENCHMARK SOIL & PERC INFO / ELEVATIONS WETS. DISCLAIMER WELLS & WETLANDS ✓ WATERSHED? DRIVEWAY -' SC(Elev) WATER LINE FDN DRAIN (,-' SCH40 L,--- TESTS CURRENT? 4' 3ccocJ /47,5' rfoM or� �ysre�j /4o?.a SEPTIC TANK � J MIN 1500G`✓/ . 17 INVERT DROP ��� GARB. GRINDER /UQ (+200% EDF) 25 ' TO CELLAR MANHOLE TO GRADE ELEV GW D-BOX SIZE # LINES FIRST 2 ' LEVEL STATEMENT INLET J¢8, 91S - OUTLET JM 76 (2 11 OR . 17 FT) TEE REQ'D?146— LEACHING / / / MIN 660 GPD? & RESERVE AREA v 4 ' FROM PRIMARY? `' 2% SLOPE 100 ' TO WETLANDS ` 100 ' TO WELLS L,,".' 4 ' TO S.H.GW 35 ' TO FND & INTRCPTR DRAINS &---' 325 ' TO SURFACE H2O SUPP 4 ' PERM. SOIL BELOW FACILITY_�C9(MIN 12" COVERy FILL? !/ (25 ' if above natural elev; 0below) BREAKOUT MET? TRENCHES MIN 660gP d SLOPE ( /min . 005 or 6" 100 ' ) >3 'COVER?-VENT ,— � SIDEWALL DIST. 2X EFF. W OR D (MIN 61 ) IS RESERVE BETWEEN TRENCHES? (eL--' IN FILL? L---' MUST BE 10 ' MIN. L--"4 11 PEA STONE? L--' BOT 0660 X LDNG ,�64 + SIDE ��� X LDNG Db = TOT (L xx W x #) (G/ft2) (DxLx2x#) (G/ft2) Copyright O 1993 by S.L.Starr cr 0222016362 4A1M \\J Commonwealth of Massachusetts Form 4--System Pumping Record Massachusetts System Pumping Record SyttFff Owner System Location AUG, 7 2007 Mrirshall Stave Pr.i.mnry Homey TOWN OF NORTH ANDOVER e6 Sunset Rock Rd 66 Sunuet Rock Rd HEALTH DEPARTMENT North Andover, 14A, 01845 North Andover, MA, 01845 (978)-685-3031 x (9781-685-3031 x Marshall Steve Type: Emergent Routine / Cesspool: No Yes Septic Tank: No = Yes Date of Pumping: Quantity Pumped: Gallons System Pumped By: Wind River Environmental,LLC Permit#: Contents Transferred to: Lr � Contents Disposed at: U Date: Pumper Signature: t Condition of System/Other Comments Dep Approved Form-12/07/95 Commonwealth of Massachusetts City/Town of System Pumping Record NORTH ANDOVER Form a DEP has provided this form for use by local Boards of Health. Other forms may be used,but the information must be substantially the same as that provided here. Before using this form,check with your local Board of Health to determine the form they use.The System Pumping Record must be submitted to the 1=1 Board of Health or other approving authority.within 14 days from the pumping date in accordance with 310 CMR 15.351. A. Facility Inf - Important: When filling out 1 ystem Location' forms on the -Rgcm t� pomputer,us _:�. _ - Y�15J�-� only the ta y Address Nvto move y r Cl 0 Y C� I " 'wrsar• not ••- —....:. .... ........ State Zip Code use the re rn Gitylfown key. 2. System Owner: V10 - 5�cvc K a.n Address of different from tacation) Cilyfrown le Zip Code TIftortork Number B. Pumping Record 1. Date of Pumping � r i — 2, Quantity Pumped: Data Gallons -- 3. Type of system: ❑ Cesspooi(s) [Septic Tank ❑ Tight Tank Q Grease Trap Other(describe); . ../. a, Effluent Tee Filter present? C1 Yes [�No if yes, was it cleaned? ❑ Yes 2 No 5. Condition of Syst m: 6. System Pumped By: l _76613b N Vehicle License Number , ..... i omnne�n l Company 7, Location where contents were disposed: G.L.S.DL Sigxeature of t tauter �i 1�sI"1. _ .Date' Sigttdture of Receiving Facifity Date r5fprm4.doc09!06 System Pumping Rewro-Page t of 1 i � �